Doh Form 5032 PDF Details

Form 5032, also known as the Doh form, is a state tax form used to report and pay sales and use taxes. This form must be filed by all businesses that engaged in taxable retail sales in Oklahoma during the preceding month. The deadline for filing this form is the 20th of the following month. There are a number of details that must be included on this form, so it's important to understand exactly what needs to be reported. This blog post will provide an overview of Form 5032 and explain some of the requirements. Keep in mind that this information is not intended to serve as legal advice; please consult with an accountant or tax attorney if you have specific questions about your business' tax obligations.

QuestionAnswer
Form NameDoh Form 5032
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdoh 5032 form, 5032 form, doh confidential, authorization for release of health info form doh 5032

Form Preview Example

 

Authorization for Release of Health Information (Including Alcohol/Drug Treatment

NEW YORK STATE DEPARTMENT OF HEALTH

and Mental Health Information) and Confidential HIV/AIDS-related Information

 

 

 

 

Patient Name

Patient Address

Date of Birth

Patient Identification Number

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:

1.This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDS-RELATED INFORMATION only if I place my initials on the appropriate line in item 8. In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 8, I specifically authorize release of such information to the person(s) indicated in Item 6.

2.With some exceptions, health information once disclosed may be re-disclosed by the recipient. If I am authorizing the release of HIV/AIDS-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from re-disclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS-related information, I may contact the New York State Division of Human Rights at 1-888-392-3644. This agency is responsible for protecting my rights.

3.I have the right to revoke this authorization at any time by writing to the provider listed below in Item 5. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

4.Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.

5.Name and Address of Provider or Entity to Release this Information:

6.Name and Address of Person(s) to Whom this Information Will Be Disclosed:

7.Purpose for Release of Information:

8. Unless previously revoked by me, the specific information below may be disclosed from:

 

until

 

 

INSERT START DATE

 

INSERT EXPIRATION DATE OR EVENT

All health information (written and oral), except:

 

 

For the following to be included, indicate the specific information to be disclosed and initial below.

Records from alcohol/drug treatment programs

Information to be Disclosed

Initials

Clinical records from mental health programs*

HIV/AIDS-related Information

9. If not the patient, name of person signing form:

10. Authority to sign on behalf of patient:

All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form.

SIGNATURE OF PATIENT OR REPRESENTATIVE AUTHORIZED BY LAW

DATE

Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the patient’s authorized representative.

STAFF PERSON’S NAME AND TITLE

SIGNATURE

DATE

 

 

 

This form may be used in place of DOH-2557 and has been approved by the NYS Office of Mental Health and NYS Office of Alcoholism and Substance Abuse Services to permit release of health information. However, this form does not require health care providers to release health information. Alcohol/drug treatment-related information or confidential HIV-related information released through this form must be accompanied by the required statements regarding prohibition of re-disclosure.

*Note: Information from mental health clinical records may be released pursuant to this authorization to the parties identified herein who have a demonstrable need for the information, provided that the disclosure will not reasonably be expected to be detrimental to the patient or another person.

DOH-5032 (4/11)

How to Edit Doh Form 5032 Online for Free

doh release of information form can be completed online effortlessly. Just try FormsPal PDF editor to complete the task without delay. The editor is continually maintained by us, getting powerful features and becoming better. Getting underway is simple! All you should do is stick to these simple steps directly below:

Step 1: Open the PDF form in our editor by pressing the "Get Form Button" at the top of this page.

Step 2: The tool allows you to modify most PDF forms in various ways. Improve it by writing customized text, adjust what is already in the PDF, and include a signature - all manageable within a few minutes!

Completing this PDF will require attention to detail. Make certain all mandatory blank fields are filled out properly.

1. The doh release of information form requires certain details to be inserted. Ensure the next fields are finalized:

Part number 1 for submitting doh 5032 form

2. Once your current task is complete, take the next step – fill out all of these fields - Unless previously revoked by me, INSERT START DATE, until, INSERT EXPIRATION DATE OR EVENT, All health information written and, For the following to be included, Records from alcoholdrug treatment, Clinical records from mental, HIVAIDSrelated Information, Information to be Disclosed, Initials, If not the patient name of, Authority to sign on behalf of, All items on this form have been, and SIGNATURE OF PATIENT OR with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Stage no. 2 in filling out doh 5032 form

Be very careful when filling out Information to be Disclosed and until, as this is the section in which many people make mistakes.

Step 3: You should make sure your details are correct and then click "Done" to complete the task. Get hold of the doh release of information form after you sign up for a free trial. Instantly use the document in your FormsPal cabinet, together with any modifications and adjustments automatically kept! FormsPal guarantees your information privacy with a secure system that never saves or shares any personal information involved in the process. Rest assured knowing your paperwork are kept protected each time you use our tools!

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